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Endoscopic surgery for tuberculum sellae meningiomas: a systematic review and meta-analysis

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Abstract

Recent reports of surgical resection of tuberculum sellae meningiomas through an endoscopic endonasal approach (EEA) have provided an alternative to transcranial approaches in selected cases. However, these published reports have been limited by small sample size from single institutions. We performed a systematic review and meta-analysis to gain insight into potential limitations and benefits of EEA for tuberculum sellae meningiomas. We performed a systematic review of the literature and analyzed pooled data for descriptive statistics on short-term morbidity and outcomes. We compared EEA to transcranial approaches reported during the same time-frame. Six studies (49 patients) met inclusion criteria for EEA. A pooled analysis of transcranial results reported during a similar time period yielded 11 studies (412 patients). There were no differences in rate of gross total resection or peri-operative complications between the two groups. Although the EEA group was associated with higher rates of CSF leak (p < 0.05; OR 3.9; 95 % CI 1.15, 15.75), EEA were also associated with significantly higher rates of post-operative visual improvement compared to transcranial approaches (p < 0.05; OR 1.5; 95 % CI 1.18, 1.82). A systematic review of the small series of EEA for tuberculum sellae meningiomas published to date revealed similar extent of resection and morbidity, but increased post-operative visual improvement compared to transcranial approaches during a similar time period. Long-term follow-up will be needed to define recurrence rates of EEA as compared to transcranial approaches. Cautious use of EEA for the removal of smaller tuberculum sellae meningiomas after formal endoscopic training may be warranted.

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Acknowledgments

A.J. is a Howard Hughes Medical Institute (HHMI) Medical Research Fellow.

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Authors and Affiliations

  1. Department of Neurological Surgery, University of California, San Francisco 505 Parnassus Ave. Rm. M779, San Francisco, CA, 94143-0112, USA

    Aaron J. Clark, Arman Jahangiri, Roxanna M. Garcia, Michael E. Sughrue, Michael W. McDermott & Manish K. Aghi

  2. Department of Otolaryngology, University of California, San Francisco, CA, USA

    Jonathan R. George & Ivan H. El-Sayed

  3. Center for Minimally Invasive Skull Base Surgery, University of California, San Francisco, CA, USA

    Aaron J. Clark, Arman Jahangiri, Jonathan R. George, Michael E. Sughrue, Michael W. McDermott, Ivan H. El-Sayed & Manish K. Aghi

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Correspondence to Manish K. Aghi.

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Comments

Siamak Asgari, Ingolstadt, Germany

The authors present a pure review about mainly retrospective studies about surgical resection of tuberculum sellae meningiomas since 2006. The authors configurated two subgroups of studies and compared them concerning rate of gross total resection, improvement rate of vision, and complication rate. Six papers describe extended endoscopic endonasal tumor (EEE) resection in 49 patients. The other subgroup contents 11 papers describing transcranial (TCM) microsurgical tumor resection in 412 patients. In comparison and supported by statistical analysis, the EEE collection showed a significant higher rate of postoperative visual improvement (50–100 versus 25–78 %). The rate of postoperative worsening of visual function was not significantly different for both groups. Additionally, the analysis depicted a significantly higher rate of postoperative CSF leaks in the EEE group (0–62 versus 0–8 %). The scientific worth of this review article is questionable. The patient number in the TCM group is about tenfold higher than in the EEE group. Even in the experience of extremely skilled microneurosurgeons, an improvement rate for visual function of 90–100 % after resection of suprasellar meningiomas seems not realistic. A tumor size of grater than 3 cm with severe functional deficit of an optic nerve is often associated with microvascular ischemia of the optic nerve and infiltration of the optic nerve sheath at the entrance into the optic canal. A possible explanation for the abovementioned statistical results is the tendency toward smaller tumors in the EEE group. A 100 % improvement rate in visual function is implausible for example comparable to some reported clinical results after surgery for multisegmental spondylotic cervical myelopathy with 90–100 % improvement rates. However, the authors mentioned the existence of the problematic tumoral feeding arteries arising from the A1 and A2 segments in the cases of large suprasellar meningiomas and how to deal with them. The high rates for CSF leakages in some reports of EEE in tuberculum sellae meningiomas are important to discuss since these complications lengthen the hospital stay of the patients and are able to induce secondary complications. Finally, both surgical approaches (EEE and TCM) showed their advantages and will remain in the neurosurgical armamentarium. I modified my experience in the treatment of tuberculum sellae meningiomas toward microsurgical excision via supraorbital keyhole approach under assisting 30° and 70° endoscopy.

Paul A. Gardner, Pittsburgh, USA

This is an interesting metaanalysis that has logical and practical conclusions. Endoscopic endonasal approaches (EEAs) were developed and advanced because of the theoretical advantage of little or no neural manipulation. For tuberculum sellae meningiomas (TSMs) this should result in minimized visual decrement and improved visual outcomes. Simultaneously, the major challenge for endonasal approaches has been CSF leak. This review confirms both this advantage and disadvantage with the best available data.

However, there are several aspects of the paper that detract from the strength of the data. Most notable is the size of available studies. 11 transcranial papers yielded 412 patients whereas 6 endoscopic papers yielded only 49 patients. The minimum number of 3 patients per study is quite low and a reflection of the lack of large study availability. Our own study, which had the greatest number, appears to statistically dominate the CSF leak data. This data is from the era before the vascularized nasoseptal flap which is recognized to significantly lower leak rates. In addition, though we believe our case series does not reflect a selection bias for EEA, the smaller series may. As a result, the overall value of this study as a meta-analysis has to be questioned. In the end, it does serve to evaluate the available data to try to provide a useful and encouraging conclusion about a new and increasingly popular approach. It also highlights the dearth of available data and need for larger, updated series with longer followup.

Makoto Nakamura, Hannover, Germany

Clark et al. present a thorough systematic review and meta-analysis which compares the surgical outcome of extended endoscopic surgery vs transcranial surgery for resection of tuberculum sellae meningiomas. Six studies (49 patients) with endoscopic surgery were compared with 11 studies (412 patients), where transcranial surgery was performed.

Review of published series revealed that there were no differences in rate of gross total resection or peri-operative complications between the two groups (endoscopic resection was associated with a 11–43 % complication rate compared to 5–28 % in the transcranial group with no statistical difference). However, CSF leak is a large concern in the endoscopically treated group. Reported rates of CSF leak were 0–62 % for the endoscopic group and only 0–8 % for the transcranial group. Few recent endoscopic series favored the use of a vascularized nasoseptal flap for dural closure; however, there is no study so far which specifically focused on tuberculum sellae meningiomas. Unless this closure technique really proves to be sufficient enough in order to reach low rates of CSF leaks comparable to the transcranial procedure, there should be no reason to prefer the endoscopic procedure instead of a straight forward transcranial route.

The authors found that the rate of post-operative worsening of visual function was 0–17 % in the endoscopic group compared to 0–24 % in the transcranial group, which was not significant. The rate of visual improvement was 50–100 % in the endoscopic group compared to 25–78 % in the transcranial group. The authors have correctly pointed out that findings regarding visual outcomes in endoscopically treated groups must be interpreted with caution. There were three distinct methods of assessing visual improvement in these 17 series. Three endoscopic studies reported visual improvement rates greater than 92 %. Of these, only one reported the use of a standard outcome measure: the visual impairment score (VIS). Further studies will clearly be needed, using the VIS as the most reliable outcome measure for visual function after surgery.

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Clark, A.J., Jahangiri, A., Garcia, R.M. et al. Endoscopic surgery for tuberculum sellae meningiomas: a systematic review and meta-analysis. Neurosurg Rev 36, 349–359 (2013). https://doi.org/10.1007/s10143-013-0458-x

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